The goal of the proposed studies and educational plan is to develop the PI into an independent investigator with the career goal of improving geriatric critical care through evidence-based delivery of palliative and end-of- life care for oldr adults in the intensive care unit (ICU). Older adults who are critically ill often undergo high- intensity care while simultaneously being at high-risk of death. This high-intensity treatment may result in significant discomfort and may not improve survival or be in-line with patients' preferences. The use of palliative care has been advocated as a strategy for realigning the intensity of care that is delivered with the intensity of care that is desired by patients and families. We have already demonstrated that among older adults, the need for palliative care consultation is common during high intensity treatment. In single-center studies, the use of palliative care in the ICU has been associated with markers of lower treatment intensity. However, with the recent expansion of palliative care programs, it is unclear if palliative care services have similar outcomes on a larger scale. Consequently, we plan to examine whether the availability of hospital- based palliative care services affects critical care outcomes for oldr adults by analyzing a merged multi-center data source created for this project. We will test the hypothesis that the presence of hospital-based palliative care services is associated with lower treatment intensity for critically ill older adults with three aims: 1) validate methods to study hospital-based palliative care services using administrative and proprietary data 2) determine if the availability of hospital-based palliative care services is associated with lower treatment intensity and 3) identify ICU and provider characteristics associated with high-penetration of palliative care within the ICU. We will accomplish these aims with quantitative methods, through analysis of a uniquely merged dataset of statewide hospital discharge data from New York State, data from the Annual American Hospital Association Survey and data from the National Palliative Care Registry, and with qualitative methods, using semi- structured interviews. This dataset will contain detailed information about patients and clinical care, hospital characteristic and operating characteristics of palliative care programs.